• Obesity and Chronic Health Conditions Are Caused in Part By Inadequate Access to Fresh Food

   

  Obesity is a risk factor for a variety of chronic conditions, including diabetes, hypertension, high cholesterol, stroke, heart disease, certain cancers and arthritis.[1] Of these conditions, it appears that diabetes is most closely linked to obesity.[2] In the U.S., between the periods from 1988-1994 and 2004-2005, diabetes increased significantly among non-Hispanic blacks. [3] In 2008, 37.3% of all Non-Hispanic blacks were obese, compared with 31.9% of non-Hispanic Whites.[4]

   

  It has been established that public health strategies designed to improve social and physical environments to create conditions for healthful eating and physical activity can be, in addition to clinical treatment, beneficial for those who are already obese.[5] As an example, "innovative public policy approaches include a variety of policy and environmental initiatives designed to increase fruit and vegetable consumption in underserved areas." [6] Thus, elimination of "food deserts" (see below) in underserved communities can help eliminate chronic diseases, such as diabetes, and help achieve greater equity in health outcomes among racial and ethnic minorities.

  ---

  [1] Flegal, K., et al.; "Prevalence and Trends in Obesity Among US Adults, 1999-2008", Journal of the American Medical Association ("JAMA"), January 20, 2010, Vol 303, No.3 at p. 235

  [2] Id.at 241

  [3] Id.

  [4] Id. at 238

  [5] Id. at 241, citing American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention.

  [6] Id., citing Jiang T, et al “Closing the grocery gap in underserved communities: the creation of the Pennsylvania Fresh Food Financing Initiative. J Public Health Manag Pract. 2008;14(3):272-279 and GlanzK et al, "Strategies for increasing fruit and vegetable intake in grocery stores and communities: policy, pricing and environmental change." Prev Med., 2004;39(suppl 2):S75-S80.

• "Food Deserts" Result in Poorer Health Outcomes

   

  There are places in the United States where no supermarkets are accessible to neighborhood residents and adequate transportation to get to distant supermarkets is unavailable.[1] Residents of these places, who tend to be members of racial and ethnic minority groups, must rely on small grocery stores or convenience stores, which carry few - if any - fresh fruits and vegetables. By contrast, these same stores carry lots of high salt and sugar laden food items.  Areas where people have poor access to fresh and healthy food are sometimes known as "food deserts".[2] People who live in food deserts are aware of their lack of accessibility to fresh fruits and vegetables and in surveys they indicate a desire to have good access to fresh produce.[3] Thus, unhealthy eating is often the result of structural inadequacies in food distribution and sale, not in personal choices around diet. [4]

   

  The connection between healthy diets and good health outcomes is well established.[5] This is readily seen, for example, with respect to diabetes and hypertension, two chronic - and preventable - diseases that disproportionately affect ethnic and racial minorities. [6] Thus, the existence of "food deserts" contributes to the continuation of racial and ethnic health disparities.

   

  Some states and municipalities, such as Pennsylvania and New York City, have undertaken programs to develop supermarkets in areas that once were food deserts.[7] In other places, programs to create easier and more efficient distribution of fresh fruits and vegetables to smaller stores, and better and less expensive refrigeration capacity in those stores, have improved the availability of fresh produce to people residing in areas that were once food deserts.

   

  Small scales measures designed to improve access to healthy foods can help change dietary habits. And the resulting change in diet for residents of former food deserts leads to better health outcomes and contributes to eliminating ethnic and racial health disparities.

   

  ---

  [1] Vehicle access is perhaps the most important determinant of whether or not a family can access affordable and nutritious food. Thus, for the total U.S. population, between 2.3

  and 5.5 percent of all households may be outside of a walking distance to a

  supermarket and lack access to a vehicle. Not surprisingly, the percentage of households without access to vehicles is higher in low-income areas.  Report to Congress, “Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences”, U.S. Department of Agriculture, June 2009, available at: http://www.ers.usda.gov/Publications/AP/AP036/AP036.pdf, at 18-20

  [2] Id. at 3.

  [3] Nearly 6 percent of all U.S. households reported that they did not always have the food they wanted or needed because of access-related problems. Id. at 6.

  [4] Id. at 15 (see, also, fn 6, infra.)

  [5] Id. at 11

  [6] Low-access to supermarkets is most heavily influenced by characteristics of neighborhood and household socioeconomic environments, such as the extent of income inequality, racial segregation, transportation infrastructure, housing vacancies, household deprivation, and rurality. This lends support to the notion that there is indeed a socioeconomic “contextual effect” that should be considered when designing food access policy. Id. at 57.

  [7] See, for example, http://www.thefoodtrust.org/php/programs/fffi.php

• Although it is commonly believed that health disparities occur simply because of a lack of health insurance and access to health care, disparities exist even after access to the health care system has been improved.

   

  For instance, new studies have shown that there are stark differences in health outcomes of black and white patients with the same conditions even when they are treated by the same doctor.[1]  Studies have shown that diagnoses, treatments, and quality of care can vary greatly depending on a number of factors that affect minority communities including language barriers, lack of insurance coverage, and differential treatments based on the population group.[2] 

   

  What these studies demonstrate is that the key to understanding and eliminating racial and ethnic health disparities is to acknowledge that they are not the result of individual behaviors; rather, poorer health outcomes and disparities in health are the result of social determinants of health care status. Therefore, the elimination of health care disparities requires solutions on a societal basis.

  ---

  [1] Sack, Kevin. "Doctors Miss Cultural Needs, Study Says." New York Times. June 10, 2009. <http://query.nytimes.com/gst/fullpage.htmlres=9B0CE5DD1E3EF933A25755C0A96E9C8B63&scp=
  2&sq=Kevin+Sack&st=nyt>  

  [2] Id.

• Racial and ethnic minorities are among the fastest growing of all communities in the U.S. and comprise approximately 34 percent of the total U.S. population. Yet data on health status point to significant evidence of poorer health outcomes among racial and ethnic minorities with respect to death and preventable disease.

   

  Some examples:

The challenge for the U.S. is to adequately address poor racial and ethnic minority health status and persistent racial and ethnic health disparities at a time of rapidly increasing racial and ethnic diversity. For more information see, "A Strategic Framework for Improving Racial/Ethnic Minority Health and Eliminating Racial/Ethnic Health Disparities", U.S. Department of Health and Human Services, Rockville, MD: Office of Minority Health, January 2008.

• Elimination of Racial and Ethnic Health Disparities Would Save the U.S. Health Care System Billions of Dollars Each Year

   

  In a report issued in September, 2009, the Urban Institute reported that, by simply addressing racial and ethnic health disparities, overall national health care costs could be reduced by nearly $24 billion per year, including $15.6 billion in the Medicare program alone. The study examined a select set of preventable diseases among the Latino and African American communities, including diabetes, hypertension and stroke, and concluded that – if the prevalence of such diseases in the African American and Latino communities were reduced to the same prevalence as those diseases occur in the non-Latino white population - $23.9 billion in health care costs would be saved in 2009 alone.

   

  As the representation of Latinos and African Americans in the general population increases, health care costs would be reduced even further by addressing racial and ethnic health disparities. Therefore, in addition to the compelling ethical and moral reasons to eliminate health disparities, there are economic reasons to do so as well.

   

  One way to meet the funding needs of health care reform is to seriously address elimination of racial and ethnic health disparities.

   

  (See the full report at http://www.urban.org/uploadedpdf/411962_health_disparities.pdf )

   

• Children suffer from racial and ethnic health disparities.

   

  As reported by First Focus[1], a children's advocacy organization, 43% of all US children (31.8 million children) are identified as belonging to a racial or ethnic minority.[2] Among school children (5-17 years old), 20% (10.9 million) speak a language other than English at home and 5% (2.8 million) are limited English proficient ("LEP") children.[3] Almost 10 million children – about 13% of all US children – have no health insurance.[4] But the rate is higher for children from racial and ethnic minorities, than for white children: 7% of white children are uninsured, contrasted with 12% of African American children and 20% of Latino children. 

   

  In addition to a lack of insurance and, therefore, a lack of general access to health care, certain disparities in health access and outcomes are particularly noticeable for children of specific racial/ethnic minorities: for Latino children, suboptimal health status and teeth conditions and problems getting specialty care; for African American children, asthma, behavior problems, skin allergies and unmet prescription needs; for Native American and Alaska Native children, hearing/visual problems, no usual source of care and unmet medical/dental needs; and for Asian/Pacific Islander children, problems getting specialty care and not seeing a doctor for the past year. [5]

  _____________________________

   

  [1] See, http://www.firstfocus.net/Download/Flores_G.pdf

  [2] U.S. Census Bureau. United States. S0901. Children Characteristics. 2007 American Community Survey. Available at: http://factfinder.census.gov/servlet/STTable?_bm=y&qr_name=ACS_2006_EST_G00_S0901&-geo_id=01000US&-ds_name=ACS_2006_EST_G00_&-_lang=en&-format=&-CONTEXT=st. Accessed 6/11/09.

  [3] Kominski RA, Shin HB, U.S. Census Bureau. Language Needs of School-Age Children. Available at: http://www.census.gov/population/www/documentation/paa2008/Language-Needs-of-School-Age-Children-PAA-2008.ppt#256,1,Language Needs of School-Age Children. Accessed 6/12/09

  [4] Roberts M, and Rhoades JA. Health Insurance Status of Children in America, First Half 1996–2007: Estimates forthe U.S. Civilian Noninstitutionalized Population under Age 18. Rockville, MD; Agency for Healthcare Research and Quality:2008. Statistical Brief #216.

  [5] http://www.firstfocus.net/Download/Flores_G.pdf, page 1

• Racial and ethnic minorities have higher rates of cancer and diabetes.
  
  These are only two of the diseases that disproportionately affect racial and ethnic minorities. African Americans are more likely to develop and die from cancer than any other racial or ethnic group. [American Cancer Society, Cancer Facts and Figures for African Americans 2007-2008]. African American men are 50% more likely to have prostate cancer, and are more likely than any other racial group to suffer colorectal cancer. Latina and Vietnamese women contract cervical cancer at two times the rate of White women. [The Commonwealth Fund, "Racial and Ethnic Disparities in Healthcare: A Chartbook", 2008] 18% of Native Americans, 15% of African Americans, and 14% of Latinos suffer from adult onset diabetes. This compares with 8% of the White population.  [Id.]. Moreover, because of reduced access to health care (see prior entries, below), treatment for these diseases is significantly lower among ethnic and racial minorities than among White persons.

   

• Higher Percentages of People, Especially Racial and Ethnic Minorities, Experience Absence of Health Insurance Than Previously Thought
   

  A March 2009 survey published by Families USA, and conducted by The Lewin Group, studied those under the age of 65 who lack health insurance in the United States. The Families USA study found that, during calendar years 2007 and 2008, 55% of Hispanic persons of any race, 40.3% of African Americans and 34% of other racial and ethnic minorities were uninsured at some time during the two year period. Although a lower percentage of all white persons were uninsured (25.8%), white persons as a whole made up 49.8% of the total uninsured population.

  Overall, 33.1% of all Americans under the age of 65 were uninsured at some point during the two year period. Most of these were blue collar workers employed in the service or agricultural sector or those employed on a part-time, temporary, seasonal, or contract basis.  Thus, the absence of health insurance is related not only to ethnic and racial background, but also to type of employment and social class.

  The study, which examined those who lacked health insurance for a month or more during the years 2007 and 2008 found a higher level of uninsured persons than U.S. Census Data, because the U.S. Census Data did not count as uninsured anyone who had health insurance at any time during a calendar year. So, for example, a person who was uninsured from January 1, 2007 through November 1, 2008 would be counted as having health insurance in 2008, even though they were without insurance for 10 months of that year. Based on this narrow analysis, the U.S. Census previously reported that 15.3% of the U.S. population was without health insurance, as compared with the 33.1% identified by the Families USA study.

  The full report, entitled "Americans at Risk: One in Three Uninsured" is available at http://www.familiesusa.org/resources/publications/reports/americans-at-risk.html
   

• Unaddressed Language Barriers Affect Health Outcomes and Access to Medical Care
  
  Without effective health provider and patient communication in a language both can understand, there is an increased risk of misdiagnosis, misunderstanding about the proper course of treatment and poorer adherence to medication and discharge instructions. The California Endowment, Health in Brief, "Improving Access to Health Care for Limited English Proficient Health Care Consumers", April 2003, Vol. 2, Issue 1 available at www.calendow.org. Health care providers from around the country have reported language difficulties and inadequate funding of language services to be major barriers to access to health care for limited English proficiency individuals and a serious threat to the quality of care they receive. Kaiser Commission on Medicaid and the Uninsured, Caring for Immigrants: Health Care Safety Nets in Los Angeles, New York, Miami and Houston at 11-111 (Feb. 2001). See also, Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health 71-72 (2002). In one study, over one quarter of limited English proficient patients who needed, but did not get, an interpreter reported that they did not understand their medication instructions. By comparison only 2% of those patients who did not need an interpreter, and 2% of those who needed an interpreter and received one, did not understand their medication instructions. Dennis P. Andrulis, Nanette Goodman, and Carol Pryor, What A Difference an Interpreter Can Make at 7, The Access Project (Apr. 2002). Language barriers also impact access to care – non-English speaking patients are less likely to use primary and preventive care and public health services and are more likely to use emergency rooms. Once at the emergency room, they receive far fewer services than do English speaking patients. Judith Bernstein, et al., Trained Medical Interpreters in the Emergency Department: Effects on Services, Subsequent Charges and Follow-up, J. of Immigrant Health, Vol. 4 No. 4 (October 2002); I.S. Watt, et al., The Health Experience and Health Behavior of the Chinese, 15 J. Public Health Med. 129 (1993); Sarah A. Fox and J.A. Stein, The Effect of Physician-Patient Communication on Mammography Utilization by Different Ethnic Groups, 29 Med. Care 1065 (1991).
   

• Poverty, Race and Ethnic Background Affect Access to Health Care and Quality of Health Care
  
  Persons with low incomes often experience worse health and are more likely to die prematurely. Poverty varies by race and ethnicity. According to the US Census Bureau, in 2002, 10% of whites were poor, 24% of African-Americans were poor, 22 % of Hispanics were poor and 10% of Asians were poor. In addition, quality of care has been demonstrated to be related to income.  The US Department of Health and Human Services has concluded that the poor have significantly poorer quality of health care and significantly less access to health care than high income persons. Poor persons were 65% more likely that high income person to lack health insurance and 67% more likely to lack a primary health care provider.
  
  Source:  National Health Care Disparities Report (2005), Agency for Health Care Research and Quality, United States Department of Health and Human Services, pp. 131-132.  (http://www.ahrq.gov/qual/nhdr05/nhdr05.pdf)